This page shows a summary of the changes you are about to make.
Please verify your changes carefully before submitting.
If you need to make any edits you can do so by selecting the plan type or plan description hyperlink to return to the election page.
When you are satisfied with your changes, please click the Submit button on the toolbar.
By clicking Submit you are acknowledging the following:
Clicking Submit serves as my electronic signature.
I have been notified that all required benefit plan documents are available electronically from the Ultipro Home Page.
I understand that the benefit choices made during open enrollment will be in effect for the current plan year.
I am authorizing my employer to deduct from my bi-weekly paycheck the amount necessary to pay for any pre-tax benefit elections made using this online enrollment system.
I further authorize future adjustments in the amount of the salary reduction in the event that the cost of coverage in any program selected is changed during the plan year.
If enrolling in the health plan I am eligible to participate in the Living Well Wellness Program & the wellness program has been explained to me.
I have received the EEOC Wellness Program Notice & Wellness Incentive Flyer.
If I am unable to meet a standard in order to earn a wellness discount that an alternative standard is available to me if requested with in 31 days of not earning the discount.
I understand that my tobacco usage status (the use of cigarettes, e-cigarettes, pipes, cigars, vaping products and/or chewing tobacco) reported will affect my insurance rates if enrolled.
I understand that I am certifying my spouse’s tobacco usage status on behalf of my spouse & that knowingly and intentionally providing false,
incomplete or misleading facts or information on any benefits acknowledgement or other document for the purpose of defrauding or attempting to defraud may result in disciplinary action including repayment of the premium surcharge.
I understand that if enrolled, my spouse’s tobacco usage status (the use of cigarettes, e-cigarettes, pipes, cigars, vaping products and/or chewing tobacco) reported will affect my insurance rates.
I understand if I (or my spouse) are not currently a smoker or user of tobacco products (cigarettes, e-cigarettes, pipes, cigars, vaping products and/or chewing tobacco ) today,
but begins to smoke or use tobacco products in the future, the Tobacco Usage Change form needs to be completed and submitted to HR timely.
If I decline a benefit, I cannot change my election to enroll in a pre-tax benefit plan unless I experience a qualifying life event.
This authorization will continue in effect unless I change my election during the annual open enrollment period, or I experience a qualifying life event.
I understand that I am responsible for initiating any change in my elections due to a qualifying life event,
as described under the "Plan", with in 31 days of such event by notifying my HR representative in writing.